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A Civil Politics Conversation

Civility
is the ability to disagree with others while respecting their sincerity and decency. Civility begins with understanding. We can best understand our political differences by first understanding the moral foundations upon which political views are built. This site features research, resources, and commentary related to the pursuit of Civility through understanding.

The folks there deserve credit for more than their famous boots, they have also pioneered ‘end of life’ care that works at the Gundersen Lutheran Health System; it preserves choice and dignity. And it also happens to be less expensive.

La Crosse became a pioneer in addressing end-of-life questions in the mid-1980s, after Hammes, a native of the city who has a doctorate in philosophy from Notre Dame, arrived at Gundersen as the director of medical humanities, charged with educating resident physicians about ethics. He noticed a “troubling pattern,” he said, in which family members struggled to make medical decisions, such as whether to continue dialysis after a stroke.

“We’d turn to the family and say, ‘We need your input. If your mother or father could speak now, what would they tell you?’ And the family would say, ‘If we only knew,’ ” said Hammes, 59. “I could see the distress. They were going to have to live with themselves, with the worry about making a mistake. This was unacceptable.”

The hospital began urging families to plan while people are healthy. For those who want help writing a directive, a physician will discuss the powers and limits of medicine and explain to family members what it means if they agree to serve as the “health-care agent.” They will also help people define the conditions under which they would no longer want treatment. Hammes said people often define this as “when I’ve reached a point where I don’t know who I am or who I’m with, and don’t have any hope of recovery.”

The directives are power-of-attorney forms that protect physicians and family members against liability, and the hospital makes clear to its doctors that they are expected to follow them. Today, more than 90 percent of people in town have directives when they die, double the national average…

…locals say it is because Gundersen and the town’s other hospital, Franciscan Skemp, have urged planning. “People here have their feet planted in the ground,” said Barbara Frank, a retired teacher. “They’re no-nonsense sorts of people, without a lot of illusion. That was the fertile soil upon which it was planted. But there’s no question it was helped by the two medical centers taking the lead and saying, ‘This is a good thing for you to do.’ “

By creating a culture of planning, this community has improved it’s citizens control of health care choices. And by coincidence, it’s also turned out to be less expensive, as none other than Newt Gingrich explains:

Let me give you an example that I find fascinating. In LaCrosse, Wisc., the Gundersen Lutheran Hospital system is, according to the Dartmouth [Atlas of Health Care], the least expensive place in America for the last two years of life. They have an advanced directive program, and over 90 percent of their patients have an advanced directive. They have electronic health records, so everybody on the staff knows what the advanced directive is. They have a very strong palliative care program for using drugs to manage pain. They have a hospice program.The result is today, the last two years of your life in costs are about $13,600. The last two years of your life at UCLA are $58,000. Now, why should Medicare pay $58,000 for the same outcome if it could pay $13,600? You can say, well, Los Angeles is more expensive; they do a couple of more complicated things. So fine. So let’s say it ought to be $20,000 at UCLA. That’s still [$38,000] less than it currently is. …

The Gundersen experience demonstrates two things: 1) End of life planning can work, and 2) We don’t need government help to do it. The Gundersen success begs the question why couldn’t Britain’s government run health care get this right (see Is ‘end of life care’ pro end of life)? Mr. Gingrich suggests:

We don’t think the politicians can ever fix this because the hospital lobby is so powerful, and the doctor lobby is so powerful, and the pharmaceutical lobby is so powerful, and the medical technology lobby is so powerful. You’re not going to politically solve this, but if I could empower you to know that, people start making choices. We know, for example, that if a doctor knows price, 60 percent of the time they will prescribe the less expensive drug, just because of their common sense. It’s practical. We know that people are willing to look at practical outcomes.

Timothy Egan’s article about Gov. John Kitzhaber and his family is touching and well written. The article intertwines two narratives, death with dignity, and universal healthcare. The implication is that the two are somehow linked, but are they really?

Can’t we have dignified death without state control of healthcare? Gov. Kitzhaber and his family were able to make their own choices regarding his parents end of life decisions. Isn’t that freedom part of the sanctity of life? Britian’s experience is that state control diminishes individual freedom, with horrifying consequences at end of life.

Congress proposes a new, independent federal agency called the Health Choices Administration, whose commissioner would create standards for insurance that you and some 285 million Americans (15 million would still not be covered) would be required to have. The commissioner would also qualify plans that meet federal requirements and determine which individuals are eligible for subsidies.

The HCA would be guided by the recommendations of the Health Benefits Advisory Committee, from the same article;

Recommendations for the essential benefits your insurance would cover, which would change with new knowledge and technology, would rest largely with the secretary of health and human services’ Health Benefits Advisory Committee. This group of up to 27, more than half of whom would be appointed by the president, would come up with lists of treatments and services that must be covered and set your copayments for any of the covered services.